6 1. Introduction With the passing of the Patient Protection and Affordable Care Act of 2010 (ACA), states will need to assess the impact of various components of the law on their health insurance markets. States across the nation will have to make key policy decisions such as how to structure their exchanges and whether to merge Individual and Small Group Markets. In addition, provisions of the ACA will drive significant changes to rating and benefit requirements in the insured markets. Public Consulting Group (PCG) has been tasked by the state of Nevada, Department of Health and Human Services for analysis of federal health care reform, and has subsequently subcontracted Gorman Actuarial, LLC (GA) to assess the impact of the ACA on the Nevada insured markets. This report presents preliminary results of this study and the information presented will assist the state of Nevada in preparing for the changes brought on by the ACA. 2. Key Findings This section outlines key findings from this study. With full implementation of the ACA, and the availability of premium and cost sharing subsidies, there will be a significant drop in the uninsured population, and the Individual Market will increase significantly. New regulations will bring considerable change to the types of benefit plans offered and the way in which rates are developed. As a result, individuals and employer groups may experience premium disruption, both favorably and unfavorably. Nevada currently has more than a half million uninsured residents, with more than half eligible for subsidies in the exchange. GA assumes that the total uninsured in Nevada in CY 2010 is 557, The ACA will expand Medicaid eligibility to 138% of Federal Poverty Level (FPL), and offer premium and cost sharing subsidies through a new health insurance exchange to those non- Medicaid individuals and families with income below 400% FPL. As described in Section 6.2, approximately 279,000 currently uninsured 2 will be eligible for subsidies in the exchange, with approximately 106,000 newly insured entering the Individual Market. 3 The Individual Market currently has 87,000 members. By , this market may grow to approximately 225, Based on the Current Population Survey (CPS), which is similar to the estimate of 545,000 from the Kaiser Family Foundation which is based on combined CY 2009 and CY2010 CPS data. 2 The total number of uninsured includes a portion of non-citizens who are not eligible for subsidies in the exchange. They have been excluded from the enrollment estimates. 3 Estimates of enrollment and member migration are used for actuarial analyses to understand impacts to overall premium and should not be used for other purposes. These estimates provide directional guidance and are not intended to be precise. 4 We assume implementation of the ACA begins on 1/1/14. However, we focus our analysis on 2016 to allow for a phase-in period. Gorman Actuarial, LLC 6

7 In addition to the current Individual Market and those coming from the currently uninsured population, approximately 43,000 members may migrate to the Individual Market from the employer-sponsored group markets, either to receive subsidies through the exchange or because their employer dropped coverage. The combined impact of the higher morbidity of new entrants to the Individual Market and more comprehensive plan design standards could cause premiums to increase on average 11-30% in the Individual Market before taking into account the available premium subsidies and ACA risk mitigation programs. GA has estimated that the new entrants to the Individual Market will have morbidity 8% to 26% worse than the current Individual Market risk pool. In addition, premiums in the Individual Market may increase on average 3% due to the new benefit plan standards. New benefit plan standards and cost sharing subsidies will provide more comprehensive coverage to members in the Individual Market. As a result, average premiums may increase 3%. Benefit plan designs in the current Individual Market have an estimated average actuarial value of % of the Individual Market has a plan with an individual medical deductible of greater than or equal to $2,500. In addition, many plans do not provide coverage for standard maternity benefits, and some do not provide behavioral health benefits. The ACA will require benefit plans (inside and outside the exchange) to provide coverage for essential benefits including those currently excluded from many plan offerings in the Individual Market. With the exception of the catastrophic plans, most plans will also be required to have a minimum actuarial value 5 of The ACA will eliminate or restrict many carrier rating practices currently prevalent in both the Individual and Small Group Markets. As a result, specific individuals and employer groups may experience premium disruptions. The ACA will eliminate health underwriting, and the ability to set rates based on gender, group size, and industry both inside and outside the exchange. Age rating will be restricted within a 3-to-1 band for adults. The rating changes will create premium changes as younger, healthier members and groups will generally pay higher premiums compared to premiums in the absence of the ACA, while older, sicker members and groups will pay less compared to premiums in the absence of the ACA. The Individual Market will experience premium volatility in Actuarial value is defined and discussed in Section 5, and provides a measure of benefit plan value. Gorman Actuarial, LLC 7

8 Premium changes were modeled after the application of premium tax subsidies. The average ranges resulted in increases as high as 78% and decreases as low as 94%. Younger individuals with high incomes may experience the largest premium increases. Low income individuals may experience the largest premium decreases after the application of premium tax subsidies. 3. Market Landscape 3.1. Data Collection Gorman Actuarial requested and received data from seven carriers in the Individual Market, eight carriers in the Small Group Market and seven carriers in the Large Group Market. Table 1 shows the carriers that responded to the data survey in each of the three market segments. Based on an estimate of the entire Nevada health insurance market 6, the carriers that responded to the survey represent approximately 88% of the Individual Market and 87% of the Small Group Market. Two carriers in the Small Group Market did not provide complete data for this market segment; therefore we have detailed data for approximately 70% of the Small Group Market. Carriers that responded to the survey represent nearly 97% of the Large Group Market, so we believe we have received responses that represent virtually the entire Large Group Market. However, one carrier accounts for nearly half the membership in the Large Group Market, and they were unable to provide detailed data on this market segment. Note that for the Small Group and Large Group Markets in particular, given the carriers that responded to the survey, the data is not representative of the Northern Nevada market. Carrier Data Responses Individual Small Group Large Group Aetna Health Inc. Aetna Life Insurance Company Anthem Coventry Health & Life Insurance Company Golden Rule Health Plan of Nevada Hometown Health Humana Sierra Health & Life Insurance United Health Care Insurance Company Table 1 Carrier Detailed Survey Respondents 7 6 NAIC 2010 Supplemental Healthcare Exhibits were used to estimate carrier market share in the Individual, Small Group and Large Group Market. 7 Anthem includes both Rocky Mountain Hospital & Medical and HMO Colorado. Even though these are two separate legal entities the data was combined for purposes of the survey and this report given the Gorman Actuarial, LLC 8

9 We generally define carrier as a separate legal entity. 8 For example, we treated Health Plan of Nevada and Sierra Health and Life Insurance Company as two different carriers. Throughout this report we have obscured each carrier s identity so that the data associated with a particular carrier cannot be identified. We use labels such as Carrier A, Carrier B, etc. Note that the carrier labels are not consistent throughout the report. This is done intentionally so that a carrier s identity may not be discerned 3.2. Individual Market As of 12/31/2010 we estimate that there were approximately 87,000 members and 58,000 subscribers in the Individual Market. 9 The membership as of 12/31/2010 and 6/30/2011 within the market is spread across carriers as shown in Table 2. The top three carriers account for approximately 75% of the membership and the top four carriers account for approximately 85% of the membership. There has been little change in the member distribution by carrier from 12/31/2010 to 6/30/2011. Market Distribution as of 12/31/2010 Market Distribution as of 6/30/2011 Carrier A 39% 37% B 19% 20% C 17% 19% D 10% 9% E 9% 8% F 4% 3% G 2% 4% Total 100% 100% Table 2 Individual Market Member Distribution by Carrier 10 Table 3 shows the Individual Market demographics as of 12/31/2010. The market is split almost evenly between males and females. 28% of the market is age 18 or younger while 25% of the market is age 50 or older. Approximately 16% of the Individual Market is between the ages of 19-29, which is the population that will be eligible for the catastrophic plans in CY This represents approximately 13,500 members. The estimated overall average age is 33. relatively small size of HMO Colorado (HMO Colorado is only offered in the Large Group Market and as of the 2010 Supplemental Health Care Exhibits represents 1% of the Large Group Market.) 8 Ibid. 9 These numbers have been adjusted to account for the carriers that did not complete the survey. 10 This distribution is based on the carriers that responded to our survey. 11 Individuals under 30 years of age or those exempt from the individual mandate because no affordable plan is available to them may purchase a catastrophic plan providing the essential benefits package with a deductible of $5,950 for a single policy ($11,900 for a family policy) and first dollar coverage for at least Gorman Actuarial, LLC 9

10 Membership Distribution as of 12/31/2010 Age Band Females Males Total % 15% 28% % 12% 23% % 12% 24% % 11% 25% Total 51% 49% 100% Table 3 Individual Market Age/Gender Distribution 12 As shown in Table 4, as of 12/31/2010, we estimate that 75% of total contracts are individual only policies, and the average family size of family contracts is 3.0. Contracts as of 12/31/2010 Individual Contracts: 75% Family Contracts: 25% Average Family Size: 3.0 Table 4 Individual Market Average Family Size Table 5 shows that the pure loss ratio in CY 2010 for the entire Individual Market is 69%. This has increased slightly from 68% in CY We define pure loss ratio as the ratio of incurred claims to premium and therefore it does not correspond to the federal MLR definition that HHS will be using for rebate purposes. The table below also shows an incurred claims PMPM (per member per month) for CY 2010 for the Individual Market. We define incurred claims as claims paid for services incurred in CY Individual Market Financials CY 2010 CY 2009 Incurred Claims PMPM $136 $133 Premium PMPM $199 $197 Pure Loss Ratio 69% 68% Table 5 Individual Market Pure Loss Ratio for CY 2010 and CY 2009 Not all carriers were able to provide complete allowed claims data. Allowed claims are defined as incurred claims plus member cost sharing. For the carriers that were able to provide allowed claims data, on average the incurred claims are approximately 66% of allowed claims in the Individual Market. In other words, on average, the member pays 33% of total medical claims. Table 6 shows the pure loss ratio by carrier. As shown, three primary care visits. These plans will not be required to meet the 0.60 minimum actuarial value standard. 12 Child only policies are not currently sold in the Nevada Individual Market. Therefore, the population under age 19 should consist of dependents and not policyholders. Gorman Actuarial, LLC 10

11 pure loss ratios range from 62% to 78% in CY The federal MLR standard for purposes of calculating rebates is 75% in CY 2011 for the Individual Market. 13 Carrier CY 2010 Pure Loss Ratio A 69% B 62% C 78% D 71% E 62% F 62% Average 69% Table 6 Individual Market Pure Loss Ratio by Carrier CY GA also analyzed the distribution of annual allowed claims by member for the Individual Market. Table 7 shows a distribution of medical claims by member and Table 8 shows a distribution of pharmacy claims by member. Approximately 1% of the population accounts for 46% of total medical costs with an estimated average annual cost of $69,000 per member. Approximately 40% of the market did not incur any medical claims in 2010 and 49% of the market did not incur any pharmacy claims in The average annual medical allowed claims is $1,498 and the average annual pharmacy allowed claims is $338 for a total annual average of $1,835. Annual Allowed Dollars CY 2010 Nevada Individual- Medical Claims Cumulative % of Claimants Cumulative % of Dollars Table 7 Individual Market CY 10 Medical Allowed Claims Distribution 15 Average Allowed Claims per Claimant $0 39.9% 0.0% $0 $1 - $ % 4.7% $212 $500 - $ % 9.2% $711 $1,000 - $4, % 27.8% $2,243 $5,000 - $9, % 40.3% $7,043 $10,000 - $24, % 56.9% $15,303 $25,000 - $49, % 68.1% $34,810 $50, % 100.0% $142,225 Total 100.0% 100.0% $1, Does not include carriers with less than 12,000 member months in CY Does not include carriers who have a large portion of their claims paid as part of a capitated arrangement. Gorman Actuarial, LLC 11

12 Annual Allowed Dollars Table 8 Individual Market CY 10 Pharmacy Allowed Claims Distribution Small Group Market 17 CY 2010 Nevada Individual- Pharmacy Claims Cumulative % of Claimants Cumulative % of Dollars Average Allowed Claims per Claimant $0 48.5% 0.0% $0 $1 - $ % 1.1% $22 $50 - $ % 2.5% $72 $100 - $ % 13.9% $241 $500 - $ % 25.2% $713 $1,000 - $4, % 64.3% $2,062 $5, % 100.0% $11,674 Total 100.0% 100.0% $338 As of 12/31/2010 we estimate that there were approximately 105,000 members and 63,000 subscribers in the Small Group Market. 18 The membership as of 12/31/2010 and 6/30/2011 within the market is spread across carriers as shown in Table 9. The top three carriers account for approximately 80% of the membership and the top four carriers account for nearly 90% of the membership. There have been small changes in the member distribution by carrier from 12/31/2010 to 6/30/2011, with some of the smaller carriers gaining market share and some of the larger carriers losing market share. Market Distribution as of 12/31/2010 Market Distribution as of 6/30/2011 Carrier A 35% 34% B 32% 30% C 13% 10% D 9% 10% E 5% 6% F 3% 4% G 3% 3% H 0% 3% Total 100% 100% Table 9 Small Group Market Member Distribution by Carrier One carrier was not able to provide pharmacy allowed claims and is therefore excluded from this table. 17 The data in this section includes associations. 18 These numbers have been adjusted to account for the carriers that did not complete the survey. 19 Note that this distribution is based on the carriers that responded to our survey. Gorman Actuarial, LLC 12

13 Table 10 shows the Small Group Market demographics as of 12/31/2010. The market is split almost evenly between males and females. 23% of the market is age 18 or younger while 24% of the market is age 50 or older. The estimated overall average age is 35, which is slightly older than the Individual Market. Membership Distribution as of 12/31/2010 Age Band Females Males Total % 11% 23% % 12% 25% % 14% 28% % 12% 24% Total 49% 51% 100% Table 10 Small Group Market Age/Gender Distribution As shown in Table 11, as of 12/31/2010, we estimate that 70% of total contracts are individual only policies, which is slightly less than the number of individual only policies in the Individual Market. The average family size of family contracts is 3.2 in the Small Group Market, slightly more than the average family size in the Individual Market. Contracts as of 12/31/2010 Individual Contracts 70% Family Contracts 30% Average Family Size 3.2 Table 11 Small Group Market Average Family Size Table 12 shows that the pure loss ratio in CY 2010 for the entire Small Group Market is 77%. This has decreased a few percentage points from 80% in CY We define pure loss ratio as the ratio of incurred claims to premium and therefore it does not correspond to the federal MLR definition that HHS will be using for rebate purposes. The table below also shows an incurred claims PMPM (per member per month) for CY 2010 for the Small Group Market. We define incurred claims as claims paid for services incurred in CY The premium includes both the employee and employer contribution portions. The incurred claims PMPM in the Small Group Market is over 70% higher than the incurred claims PMPM in the Individual Market. This is driven in part by the demographics and health status of the Individual Market compared to the Small Group Market, but also to a larger extent the differences in benefit designs between the two market segments. In general, the benefit offerings in the Small Group Market are much richer than in the Individual Market. This will be explored further in Section 5. Gorman Actuarial, LLC 13

14 Small Group Market Financials CY 2010 CY 2009 Incurred Claims PMPM $234 $230 Premium PMPM $305 $289 Pure Loss Ratio 77% 80% Table 12 Individual Market Pure Loss Ratio for CY 2010 and CY 2009 Not all carriers were able to provide complete allowed claims data. Allowed claims are defined as incurred claims plus member cost sharing. For the carriers that were able to provide allowed claims data, on average the incurred claims are approximately 77% of allowed claims in the Small Group Market. In other words, on average, the member pays 23% of total medical claims. This compares to the 33% in the Individual Market, demonstrating the difference in cost sharing between the Small Group and Individual Markets. Table 13 shows the pure loss ratio by carrier. As shown, pure loss ratios range from 62% to 117% in CY The federal MLR standard for purposes of calculating rebates is 80% in CY 2011 for the Small Group Market. Carrier CY 2010 Pure Loss Ratio A 117% B 64% C 62% D 67% E 82% F 76% G 78% Average 77% Table 13 Small Group Market Pure Loss Ratio by Carrier CY GA also analyzed the distribution of annual allowed claims by member for the Small Group Market. Table 14 shows medical claims by member and Table 15 shows pharmacy claims by member. Approximately 1% of the population accounts for 39% of total medical costs, with an estimated average annual cost of $84,000 per member. Approximately 36% of the market did not incur any medical claims in 2010 and 41% of the market did not incur any pharmacy claims in The average annual medical allowed claims is $1,969 and the average annual pharmacy allowed claims is $503 for a total annual average of $2,472. This is significantly higher as compared to the Individual Market allowed annual average of $1,835. This comparison is based on allowed claims, which includes member cost sharing. So while the difference between the total allowed average of $2,472 in the Small Group Market and the total allowed average of $1,835 in the Individual Market is not driven by cost sharing differences, it is driven by utilization, demographics, and health status differences. 20 Does not include carriers with less than 12,000 member months in CY Gorman Actuarial, LLC 14

16 3.4. Large Group Market As of 12/31/2010 we estimate that there were approximately 66,000 members and 38,000 subscribers in the Large Group Market. 23 The membership as of 12/31/2010 and 6/30/2011 within the market is spread across carriers as shown in Table 16. The top three carriers account for approximately 88% of the membership. Carrier A did not provide a complete data survey and therefore is not included in some of the subsequent tables and analyses. 24 In places where their data was not available, this is noted. There have been some changes in the member distribution by carrier from 12/31/2010 to 6/30/2011, with two carriers in particular gaining some market share and one carrier losing some market share. Carrier Market Distribution as of 12/31/2010 Market Distribution as of 6/30/2011 A 51% 53% B 24% 23% C 13% 10% D 6% 8% E 4% 4% F 1% 1% G 1% 1% H 0% 1% Total 100% 100% Table 16 Large Group Market Member Distribution by Carrier 25 Table 17 shows the Large Group demographics as of 12/31/2010. The market has slightly more females. 24% of the market is age 18 or younger while 27% of the market is age 50 or older. The estimated overall average age is 35, similar to the Small Group Market. Membership Distribution as of 12/31/2010 Age Band Females Males Total % 12% 24% % 10% 22% % 13% 28% % 13% 27% Total 52% 48% 100% Table 17 Large Group Market Age/Gender Distribution These numbers have been adjusted to account for the carriers that did not complete the survey. 24 While GA recognizes that this carrier represents a large portion of the Large Group segment, we have chosen to include the data when possible. 25 Note that this distribution is based on the carriers that responded to our survey. Gorman Actuarial, LLC 16

17 As shown in Table 18, as of 12/31/2010, we estimate that 63% of total contracts are individual only policies, and the average family size of family contracts is 3.0. Contracts as of 12/31/2010 Individual Contracts 63% Family Contracts 37% Average Family Size 3.0 Table 18 Large Group Market Average Family Size 27 Table 19 shows that the pure loss ratio in CY 2010 for the Large Group Market is 78%. 28 This is consistent with the pure loss ratio in CY We define pure loss ratio as the ratio of incurred claims to premium and therefore it does not correspond to the federal MLR definition that HHS will be using for rebate purposes. In CY 2010 the Large Group Market incurred claims PMPM is 2.6% lower than the Small Group Market and the premium PMPM is 3.9% lower. The differences may be due to slight morbidity or plan design differences. Large Group Market Financials CY 2010 CY 2009 Incurred Claims PMPM $228 $223 Premium PMPM $293 $285 Pure Loss Ratio 78% 78% Table 19 Large Group Market Pure Loss Ratio for CY 2010 and CY Table 20 shows that the pure loss ratio in CY 2010 for the entire Large Group Fully Insured Market is 81%. The overall incurred claims PMPM and premium PMPM for the entire Large Group Fully Insured Market are lower than the portion of this market while the overall pure loss ratio is three percentage points higher. The portion of the Large Group Market represents approximately 18% of the number of members in the entire Large Group Fully Insured Market. The Large Group incurred claims and premium are 9% and 13% higher than the incurred claims and premium in the entire Large Group Market respectively. Note that while we requested information on the Large Group self-insured markets in Nevada for both the segment and the entire Large Group segment, carriers either stated that they did not have any self-insured business or declined to provide this information. 26 Carrier A from Table 16 is included in this data. 27 Ibid. 28 Carrier A from Table 16 is not included as their financial information was not provided. 29 Ibid. Gorman Actuarial, LLC 17

18 Large Group Market Financials CY 2010 Incurred Claims PMPM $210 Premium PMPM $260 Pure Loss Ratio 81% Table 20 Large Group 51+ Market Pure Loss Ratio for CY 2010 Table 21 shows the pure loss ratio by carrier for both the Large Group segment and the entire 51+ segment. As shown, the pure loss ratios are within a close range for the segment, ranging from 75% to 78% in CY In the 51+ segment, pure loss ratios vary between 74% and 91%. Note that there are more data points in this segment due to the increased credibility of this segment. Large Group CY 2010 Pure Loss Ratio Table 21 Large Group Market Pure Loss Ratio by Carrier CY , Comparison of Market Segments Large Group 51+ CY 2010 Pure Loss Ratio Carrier A 74% 74% B n/a 86% C 78% 82% D 75% 75% E n/a 91% F 77% 83% Average 78% 81% Table 22 provides an overview of the Nevada health insurance market in This is based on information from the carrier survey data and publicly available information from the Kaiser Family Foundation State Health Facts for the nonelderly population in the state of Nevada. 32,33 In total, there is an estimated 2.3 million nonelderly residents in Nevada in 2010, of which 23% are uninsured, 15% are covered by public programs, 37% are in self-insured arrangements, and the remaining 24% or 557,000 members are in the fully insured commercial market. On a national basis, 18% of the nonelderly population is uninsured and 20% are covered by public programs Does not include carriers with less than 12,000 member months in CY Carrier A from Table 16 is not included as their financial information was not provided The estimate of self-insured is based on the difference between the total employer count from the Kaiser Family Foundation less the insured population as estimated from the carrier survey data and the NAIC Supplemental Health Care Exhibits. The total of other public insurance is based on the estimate from the Kaiser Family Foundation along with the difference between the individual counts from the Kaiser Family Foundation and the carrier survey data. 34 Gorman Actuarial, LLC 18

19 Table 22 Nonelderly Health Insurance Market Overview 2010 Figure 1 depicts the member distribution in the Nevada fully insured markets as of 12/31/2010. Overall, the Large Group represents 66% of the fully insured markets, while the Individual and Small Group Markets represent 15% and 19% respectively. The Large Group segment accounts for 12% of the total fully insured market (or 18% of the entire Large Group Market) while the Large Group 100+ segment accounts for 54% of the total market (or the remaining 82% of the Large Group Market.) Gorman Actuarial, LLC 19

20 Figure 1 Fully Insured Member Distribution by Market Segment 12/31/2010 When we examine just the portion of the market represented by individuals and employer groups with less than 100 employees, 34% of the members are in the Individual Market, 41% of the members are in the Small Group Market and the remaining 25% are in the Large Group Market segment as of 12/31/2010. This is depicted in Figure 2. Figure 2 Fully Insured Member Distribution up to 100 by Market Segment 12/31/2010 Gorman Actuarial, LLC 20

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